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Care Transitions Programs: A Review of Hospital-Based Programs Targeted to Reduce Readmissions

Delisle, Dennis R. MHSA, PMP

doi: 10.1097/NCM.0b013e31829d9cf3

Purpose/Objectives: An emphasis on a value-based payment model is expected to provide motivation for developing effective care transitions programs. For such programs to succeed, organizations must adopt an evidence-based, financially feasible model that enables improved coordination with providers, alignment of incentives, and measurement of key performance metrics, both clinical and operational. Evidence of cost-effective care transitions programs is important for deploying successful models broadly.

Primary Practice Setting(s): Hospital-based programs.

Findings/Conclusions: Current literature on care transitions programs highlights different strategies, patient populations, settings, and outcomes; however, it lacks sufficient supporting financial evidence that these programs are operationally sustainable and cost-effective within current and projected reimbursement schemes.

Implications for Case Management Practice: Care transitions interventions need to be further studied in different settings with different patient populations to identify the optimal approach(es). An additional opportunity for future investigation lies in translation of interventional programs targeted at readmission diseases in line for penalty by Medicare.

Dennis R. Delisle, MHSA, PMP, is Operational Excellence Manager for Thomas Jefferson University Hospitals and Adjunct Instructor for Thomas Jefferson University's School of Population Health. Dennis is a certified Lean Master, Six Sigma Black Belt, and project management professional and is currently pursuing a Doctor of Science degree in Health Systems Management. He is responsible for the education and certification of Lean professionals, as well as the strategic deployment of organizational initiatives. Dennis also coleads Jeffersons Performance Excellence program.

Address correspondence to Dennis R. Delisle, MHSA, PMP, Thomas Jefferson University Hospitals, 111 South 11th Street, Suite 1940, Philadelphia, PA 19107 (

The author reports no conflicts of interest.

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.